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Medical Intake Form for Dermaplaning

Please select who will be participating...
AdultMinor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Place of Employment & Phone Number *

Email Address: *

Primary Physician (Name & Phone Number) *
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Skin Concerns:
How would you describe your skin? *
Oily
Dry
Combination
Sensitive
Reactive
What concerns you most about the overall appearance of your skin? Please check all that apply. *
Acne, Acne Scarring, Blackheads, Cysts/Nodules, etc.
Age Spots, Fine Lines/Wrinkles, Sagging Skin, etc.
Broken Blood Vessels, Facial Veins, etc.
Bumps on Back of Arms
Cellulite
Dehydrated Skin, Dull Complexion, Rough Uneven Skin Texture, etc.
Excessive Facial Hair
Frequent Breakouts, Large Pores, Oily Skin, etc.
Loss of Lashes/Brows
Melasmal/Brown Spots/Patches or Sun Damage
Redness or Rosacea
Under Eye Puffiness/Dark Circles
Other

If you checked "Other", please explain
How would you describe your stress level?*
Do you feel your stress level may be affecting the health of your skin*
Yes
No

Please list current skincare routine (e.g. Proactiv Cleanser, Three Milk Moisturizer, Facial Oil, etc.)

Medical History:
Are you currently under the care of a physician?*
Yes
No

Explain:

Are you in good health overall?*
Yes
No

If no to the above question, please list concerns:

Do you have any allergies to foods, skin care ingredients or medications?*
Yes
No

If yes, please list:

Are you currently taking any medications topical or oral?*
Yes
No

If yes, please list:

Do you have any of the following medical conditions or take any of the following medications: (Please Mark All That Apply) *
Cancer
Diabetes
Blood Thinners
High Dosages/Frequent Use of Aspirin
Taking Acutane or a similar Acne Medications
No
How do you heal after an acne breakout, cut or scratch? *
No Scar
White
Red
Brown (PIH)
Do you smoke?*
Yes
No
Are you prone to cold sores?*
Yes
No

If yes, date of last cold sore?
Do you have an allergy to Latex?*
Yes
No
Do you tan in the sun or in tanning beds/booths?*
Yes
No
The answers I have provided are true and correct to the best of my knowledge.

Intial *

Date *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Place of Employment & Phone Number *

Email Address: *

Primary Physician (Name & Phone Number) *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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